Reducing Gaps in Health:A Focus on Socio-Economic Status in Urban Canada

Released:November 24, 2008

Canadian Institute for Health Information (CIHI)• Who: an independent, not-for-profit organization

providing essential data and analysis on Canada’s health system and the health of Canadians

• What: comparable information; databases supported by standards; pan-Canadian analyses

• When: opened its doors in 1994

• Where: Victoria, Edmonton, Toronto, Ottawa, Montréal and St. John’s

• How: through partnerships with stakeholders

About the Canadian Population Health Initiative (CPHI)

CPHI’s Mission:

• To foster a better understanding of factors that affect the health of individuals and communities; and

• To contribute to the development of policies that reduce inequities and improve the health and well-being of Canadians.

CPHI’s Strategic Functions

Policy Synthesis

Knowledge Exchange

Knowledge Generation

Knowledge Transfer

CPHI’s Key Themes, 2007 to 2010

Promoting Healthy WeightsMental Health and Resilience Place and Health

Reducing Gaps in Health

CPHI Council Members (as of May 2008)• Cordell Neudorf (Chair)

• David Allison

• Nancy Edwards

• Judy Guernsey

• Deborah Schwartz

• Ian Potter (ex officio)

• Michael Wolfson (ex officio)

• André Corriveau

• Brent Friesen

• Richard Massé

• Elinor Wilson

• Gregory Taylor (ex officio)

Expert Advisory Group Members for This Report• Cordell Neudorf (Chair), Chief Medical Health Officer, Saskatoon

Health Region, Saskatchewan

• Robert Choinière, Chef d’unité scientifique (lead, scientific unit), Institut national de santé publique du Québec, Quebec

• Joy Edwards, Manager, Population Health Assessment, Population Health and Research, Capital Health, Alberta

• Yanyan Gong, Methodologist, Health Indicators, CIHI, Ontario

• Denis Hamel, Statistician, Institut national de santé publique du Québec, Quebec

• Barbara Harvie, Director, Clinical Information, Nova Scotia Department of Health, Nova Scotia

Expert Advisory Group Members for This Report (cont’d)

• Bill Holden, Senior Planner, City of Saskatoon, Saskatchewan

• Glenn Irwin, Director, Data Development and Research Dissemination Division, Applied Research and Analysis Directorate, Health Canada, Ontario

• Julie McAuley, Director, Health Statistics Division, Statistics Canada, Ontario

• David McKeown, Medical Officer of Health, Toronto Public Health, Ontario

• Nazeem Muhajarine, Research Faculty, Saskatchewan Population Health and Evaluation Research Unit (SPHERU) and Department Head, Community Health and Epidemiology, University of Saskatchewan, Saskatchewan

Project Background

• In 2004, CPHI released its first Improving the Health of Canadians report– One chapter of that report examined income and the health

consequences of income, including trends and interpretations of gradients in health.

• In 2006 CPHI released Improving the Health of Canadians: An Introduction to Health in Urban Places– The 2006 report examined neighbourhoods and health, housing

and health, and urban living and health as a starting point for generating discussion about the health of urban Canadians.

Project Background (cont’d)

• Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada was born out of a partnership between CPHI and the Urban Public Health Network (UPHN).

• The nature of the partnership is to further explore the links between socio-economic status (SES) and health in Canada’s urban areas.

Objective of CPHI’s “Reducing Gaps in Health” Report

To provide a broad overview of the links between SES and health in 15 Canadian census metropolitan areas (CMAs) by examining how health, as measured by a variety of indicators, varies in small geographical areas in those CMAs with different socio-economic characteristics.

CMAs Chosen for Analyses

15 CMAs that provide a broad geographic representation of Canada’s urban areas were chosen:

• Victoria • Regina • Ottawa–Gatineau

• Vancouver • Winnipeg • Montréal

• Calgary • London • Québec

• Edmonton • Hamilton • Halifax

• Saskatoon • Toronto • St. John’s

Geographical Location of the 15 CMAs

Structure of the Report

• Section 1. The Urban Lens: What Do We Know About the Links Between Socio-Economic Status and Health? – Provides a brief overview of the multiple links between SES and health in

urban Canada.

• Section 2. Socio-Economic Status and Health in Canada’s Urban Context – Presents new CPHI analyses for 15 CMAs through an examination of

hospitalization rates and self-reported health percentages across all 15 CMAs; steepness of gradients, both within and across those 15 CMAs; regional and CMA-level analyses; and CMA-to-pan-Canadian data comparisons for select indicators.

• Section 3. Dimensions of Socio-Economic Status and Urban Health: A Policy Perspective– Provides a few examples of types of policies and interventions that are

directly or indirectly linked to SES and health at municipal, provincial, federal and international levels. A number of questions are raised that may lead to future policy-related research.

The Urban Lens

• “Being poor is in itself a health hazard; worse, however, is being urban and poor.”

–de la Barra

• A Canadian study using 1996 census data found that “central cities” or the urban core of Canada’s largest cities had a poverty rate about 1.7 times that of the surrounding suburban areas (27% in the urban core versus 16% in suburban areas).

The Urban Lens: Income

• A 2007 Canadian study found that the people in Canada’s urban neighbourhoods earning the highest income lived about three years longer than those earning the lowest income.

• In addition:– There was an increased number of deaths in

Canada’s poorest neighbourhoods.– Fewer residents of the poorest neighbourhoods are

expected to survive to age 75.

The Urban Lens: Potential Cost Savings by Reducing the Gaps

• A five-year Canadian study examined the potential cost savings that could be realized by reducing gaps in health across SES among Winnipeg residents. – The study revealed that bridging gaps in health that

exist between Winnipeg neighbourhoods to the standards of the wealthiest neighbourhoods would have resulted in a savings of about $62 million in 1999—or 15% of all hospital and physician expenditures in Winnipeg in 1999.

Methodology

Literature Search

• An extensive search of academic and grey literature on social and economic inequalities in health as they relate to urban areas:– Initial journal search: 17,024 records– Screened for date, language, geography: 9,616 articles– Reviewed titles, abstracts: 1,704 articles– Sorted by study type, research focus, year of publication,

location of study, research hypothesis, sample descriptors, measures, outcomes, study strengths and limitations: 984 articles remained

• A detailed methods paper outlines the literature search

What Is the Deprivation Index?

• A tool for measuring (quantifying) two forms of deprivation:1. Material deprivation—such as income, education and

employment ratios

2. Social deprivation—such as family structure, marital status and incidence of persons living alone.

• Allows for comparisons of small, homogeneous groups of individuals.

• Allows a variety of socio-economic indicators to be analyzed based on their known relationship with health (for example, income, education and marital status).

Benefits of Using the Institut national de santé publique du Québec (INSPQ) Deprivation Index:

• Accounts for both material and social factors when assigning an overall deprivation score.– Geographical areas are assigned into one of five quintiles

(five groups of 20%) for both material and social deprivation, ranging from the 20% least deprived to the 20% most deprived on each of those factors.

• Allows data to be presented at smaller levels of geography than other indices—at Statistics Canada’s dissemination area (DA) level.

SourcePampalon and Raymond (2000).

Moving From Social and Material Quintiles to Low, Average or High SES

• Quintile 1 = the 20% least deprived

• Quintile 5 = the 20% most deprived

• DAs with material and social combinations found in the top-left (shaded) portion of the matrix below were categorized by CPHI as “high SES.” DAs found with material and social combinations found in the bottom-right (shaded) portion of the matrix were categorized by CPHI as “low SES.” All other DAs were categorized as “average SES.”

Applying the Deprivation Index to 15 Canadian CMAs• DAs in each of the 15 CMAs were classified as either urban or rural

—those that were identified as rural were excluded from the analyses.

• 30,294 urban DAs were included in the analyses, representing about 66% of all DAs classified as urban by CPHI (46,173 DAs).

• Those urban DAs were assigned a deprivation score of low SES, average SES or high SES relative to their region (British Columbia, Alberta, Manitoba/Saskatchewan, Ontario, Quebec and Nova Scotia/ Newfoundland and Labrador).

• Age-standardized hospitalization rates and self-reported health indicator percentages were calculated within the three SES groups for each of the 15 CMAs and for all 15 CMAs collectively (CPHI’s pan-Canadian data).

Deprivation Index Applied to Victoria CMA, British Columbia

Data Analysis Plan

• 21 indicators are presented for each CMA by SES group

• Analysis based on Statistics Canada DAs allowed the following comparisons:– between SES groups within

each CMA for each indicator– between CMAs and the

overall pan-Canadian rate for each indicator within each SES group Québec CMA,

Quebec

CIHI Indicators

• Ambulatory care sensitive conditions (ACSC)

• Diabetes

• Chronic obstructive pulmonary disease (COPD)

• Asthma in children

• Injuries

• Land transport accidents

• Unintentional falls

• Injuries in children

• Mental health

• Anxiety disorders

• Affective disorders

• Substance-related disorders

• Low birth weight*

* Rate per 100 live births and not age standardized.

Age-standardized hospitalization rates (2003–2004 to 2005–2006) for longer-term chronic health problems and acute conditions were analyzed:

Statistics Canada Indicators

• “Excellent” or “very good” self-rated health (ages 12 and over; age standardized)

• Physically inactive (ages 12 and over; age standardized)

• Smoking (ages 12 and over; age standardized)

• Alcohol binging (ages 12 and over; age standardized)

• Overweight or obese (ages 18 and over; age standardized)

• Risk factor index, that is, 3 or 4 of the following (physically inactive, smoking, alcohol binging, overweight or obese) (ages 18 and over; age standardized)

• Influenza immunization (ages 65 and over)

• Activity limitation (ages 65 and over)

A subset of the Canadian Community Health Survey (CCHS) data from cycles 2.1 (2003) and 3.1 (2005) were combined to tabulate the percentage of people reporting excellent or very good health, as well as reporting certain health-related behaviours:

Socio-Economic Statusin Urban Canada:What Do the Data Tell Us?

Pan-Canadian Age-Standardized Hospitalization Rates by SES Group*

Hospitalization Rates

Note* For each indicator, all rates are significantly different between low-, average- and high-SES groups at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database and National Trauma Registry data, Canadian Institute for Health Information.

Pan-Canadian Age-Standardized Self-Reported Health Percentages by SES Group*

Self-Reported Health

Note* For each indicator, all rates are significantly different between low-, average- and high-SES groups at the 95% confidence level except for overweight/obese, where there is no significant difference between average- and high-SES groups.SourceCPHI analysis of Canadian Community Health Survey, cycles 2.1 (2003) and 3.1 (2005), Statistics Canada.

Pan-Canadian Ratio of Age-Standardized Hospitalization Rates Between Low- and High-SES Groups

Pan-Canadian Ratios for Hospitalization Indicators

SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database and National Trauma Registry data, Canadian Institute for Health Information.

Pan-Canadian Ratios for Self-Reported Health IndicatorsPan-Canadian Ratio of Age-Standardized Percentages of Self-Reported Health Between Low- and High-SES Groups

SourceCPHI analysis of CCHS, cycles 2.1 (2003) and 3.1 (2005), Statistics Canada.

Pan-Canadian and Victoria CMA Age-Standardized Self-Rated “Very Good” or “Excellent” Health by SES Groups*

Self-Rated Excellent or Very Good Health

Note*Average- and high-SES group rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of CCHS, cycles 2.1 (2003) and 3.1 (2005), Statistics Canada.

Pan-Canadian and Vancouver CMA Age-Standardized Hospitalization Rates for Mental Health by SES Group*

Mental Health Hospitalization Rates

Note*All rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database data, Canadian Institute for Health Information.

Pan-Canadian and Regina CMA Age-Standardized Hospitalization Rates for Ambulatory Care Sensitive Conditions by SES Group*

ACSC Hospitalization Rates

Note*All rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database data, Canadian Institute for Health Information.

Pan-Canadian and Winnipeg CMA Age-Standardized Hospitalization Rates for Injuries by SES Group*

Injury Hospitalization Rates

Note*Average- and low-SES group rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 National Trauma Registry data, Canadian Institute for Health Information.

Pan-Canadian and Québec CMA Age-Standardized Hospitalization Rates for Substance-Related Disorders by SES Group*

Substance-Related Disorder Hospitalization Rates

Note*All rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database data, Canadian Institute for Health Information.

Pan-Canadian and Halifax CMA Age-Standardized Hospitalization Rates for Asthma in Children by SES Group*

Asthma in Children Hospitalization Rates

Note*All rates are significantly different from pan-Canadian rates at the 95% confidence level.SourceCPHI analysis of 2003–2004 to 2005–2006 Discharge Abstract Database data, Canadian Institute for Health Information.

Reducing Gaps in Health: Policies and Programs

Demographic and Socio-Economic Characteristics Can Differ Widely Between CMAs

• Questions:– To what extent can accounting for demographic and

socio-economic characteristics help in producing actionable interventions to address gaps in health?

– Would interventions targeted toward those who are over-represented in low-income populations help to reduce gaps in health?

What Policies Seem to Be Working in Other Countries?• Evidence from the United Kingdom: “Tackling

Inequalities in Health: A Programme for Action”– Interventions geared toward major elements contributing to gaps

in health (e.g. smoking, heart disease and teenage pregnancy)– Significant narrowing of gaps in infant mortality, heart disease

and cancer mortality

• Evidence from Sweden: A National Public Health Policy– Focused on development of social capital, reduction of income

inequality and relative poverty, and increased employment– Reductions in smoking rates across the entire population;

illicit drug use among school-aged children; and work and traffic accidents

Examples of Policies and Programs That Seem to Be Working in Canada

• Federal level: Income support for seniors and children– 6% of seniors live below Statistics Canada’s low income cut-off

(LICO) versus 11% for the rest of the population (2005)– LICO rate in children decreased from 19% (1996) to 12% (2005)

• Provincial level: Mother-Baby Nutrition Supplement Program (Newfoundland and Labrador)– Participants received monthly financial supplements to help

defray cost of food throughout pregnancy– Birth weight of children was significantly higher for mothers who

received benefits in all trimesters of their pregnancies

Examples of Policies and Programs That Seem to Be Working in Canada(cont’d)

• Municipal level: The “Yes, I Quit” smoking cessation program in St. Henri, Montréal, Quebec– A trained community facilitator provided low-income women

with strategies to help them quit smoking (such as stress-coping mechanisms and strategies to avoid weight gain)

– At one-, three- and six-month follow-up, 31%, 25% and 22% of participants, respectively, reported that they had quit smoking

Improving the Evidence Base for Policy-Making• Social determinants of health often cannot be

examined in a scientifically randomized fashion.

• Natural experiments may take the form of observational studies in which researchers monitor, rather than control, the distribution of an intervention to a particular group of people.

• Natural experiments can provide opportunities for strengthening the knowledge base for informed policy decision-making.

Addressing Research-Policy Gaps

• Benefits of engaging policy-makers throughout the entire research process include:– Helps researchers to anticipate end-user needs so that they can

better tailor the design of research products for policy-makers;– Provides policy-makers with access to timely and relevant

research results;– Fosters a mutually beneficial relationship where research

informs policy and policy needs inform research;– A better understanding of research results by highlighting key

points from a policy perspective; and – An efficient working relationship that draws on the specific skills

and strengths of researchers and policy-makers.

Conclusions

Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada Key Messages• The analyses demonstrated differences—to varying degrees—in

hospitalization rates and self-reported health percentages within and across the 15 CMAs.

• Those differences were associated with SES, measured at the smallest geographical unit possible—Statistics Canada’s DAs.

• Age-standardized indicator rates were generally higher for the low-SES group than for the average-SES group and generally higher among the average group than for the highest-SES group with the extent of the gaps varying among indicators.

• There are variations in the degree of these gaps among the 15 CMAs profiled. Observable differences were noted between CMAs for some of the indicators examined.

What Do We Still Need to Know?

• What lies behind admissions for conditions for which hospitalization is potentially avoidable? To what extent are hospitalizations for ambulatory care sensitive conditions, for example, a proxy for access to primary care? What other factors may be related to such hospitalizations?

• To what extent are differences between CMAs in terms of economic, social, demographic and other factors related to differences in health outcomes between and within CMAs?

• How are differences in population composition (that is, percentage of recent immigrants, Aboriginal Peoples and single-parent families) and population trends (that is, population growth rates) related to differences within and between CMAs?

• Which interventions or combinations of interventions are most likely to reduce gaps in health within and across urban areas?

• What are the financial costs associated with gaps in SES and health?

• Do policies that are effective in improving SES also lead to positive health outcomes and reductions in gaps in health?

Conclusion

• New CPHI analyses of 15 Canadian CMAs emphasize the complex relationship between SES and health in urban Canada.

• The report demonstrates that significant differences exist between each SES group in 20 of the 21 health indicators examined.

• The report provides evidence to support the value of examining gaps in health across an SES gradient rather than focusing on the two dichotomous extremes (that is, high versus low SES).

Institut national de santé publique du Québec

Statistics Canada

Urban Public Health Network

Our Partners

cphi@cihi.ca www.cihi.ca/cphi

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